CIHM 
Microfiche 
Series 
(Monographs) 


ICMH 

Collection  de 
microfiches 
(monographies) 


Canadliin  Institute  for  Historical  Mirroreproductions  /  In. .  .ut  canadicn  d>i  microropro<luctions  historiquos 


1999 


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Technical  and  Bibliographic  Notes  /  Notes  techniques  et  bibliographiques 


The  k  te  has  attempted  to  obtain  the  best  original 
copy  ^. v.. ..able  lor  filming.  Features  of  this  copy  which 
may  1-'=-  :  :o;i  >.]raphic=;liy  unique,  which  may  alter  any  of 
thf  "TTOS  in  the  reproduction,  or  which  may 
siG:;.tic.antly  cnange  the  usual  method  of  filming  are 
chectv/j  oelovv 


□ 


Coloured  covers  / 
Couverture  de  couleur 


I      I    Covers  damaged  / 


Couverture  endommagee 


□    Covers  restored  and/or  laminated  / 
Couverture  restauree  et/ou  pelliculee 

Cover  title  missing  /  Le  titre  de  couverture  manque 

I I    Coloured  maps  /  Carles  geographiques  en  couleur 

□    Coloured  ink  (i.e.  other  than  blue  or  black)  / 
Encre  de  couleur  (i.e.  autre  que  bleue  ou  noire) 

□    Coloured  plates  and/or  illustrations  / 
Planches  et/ou  illustrations  en  couleur 


Bound  with  other  material  / 
Relie  avec  d'autres  documents 

Only  edition  available  / 
Seule  edition  disponible 

Tight  binding  may  cause  shadows  or  distortion  along 
interior  margin  /  La  reliure  serree  peut  causer  de 
I'ombre  ou  de  la  distorsion  ie  long  de  la  marge 
inteneure. 

Blank  leaves  added  during  restorations  may  appear 
within  the  text.  Whenever  possible,  these  have  been 
omitted  from  filming  /  II  se  peut  que  certaines  pages 
blanches  ajoutees  lors  d'une  restauration 
apparaissent  dans  le  texte,  mais,  iorsque  cela  etait 
possible,  ces  pages  n'ont  pas  ete  filmees. 

Additional  comments  / 
Commentaires  supplementaires; 


D 


D 


D 


L'Institut  a  microfilme  le  meilleur  exemplaire  qu'il  lui  a 
ete  possible  de  se  procurer.  Les  details  de  cet  exem- 
plaire qui  sont  pout-etre  uniques  du  point  de  vue  bibli- 
ographique,  qui  peuvent  modifier  une  image  reproduite, 
ou  qui  peuvent  exiger  une  modification  dans  la  metho- 
de  normale  de  filmage  sont  indiques  ci-dessous. 

Coloured  pages  /  Pages  de  couleur 

I I    Pages  damaged  /  Pages  endommagees 


n 


Pages  restored  and/or  laminated  / 
J    Pages  restaurees  et/ou  pelliculees 


Pages  discoloured,  stained  or  foxed  / 
Pages  decolorees,  tachetees  ou  piquees 


□ 

I  Pages  detached  /  Pages  detachees 

,'  Showthrough /Transparence 

I      I  Quality  of  print  varies  / 


n 


n 


Qualite  inegale  de  I'impression 

Includes  supplementary  material  / 
Comprend  du  materiel  '".upplementaire 

Pages  wholly  or  partially  obscured  by  errata  slip' 
tissues,  etc.,  have  been  refilmed  to  ensure  the  be".i 
possible  image  /  Les  pages  totalement  ou 
partiellement  obscurcies  par  un  feuillet  d'errata,  une 
pelure,  etc.,  ont  ete  filmees  a  nouveau  de  fagon  a 
obtenir  la  meilleure  image  possible. 

Opposing  pages  with  varying  colouration  or 
discolourations  are  filmed  twice  to  ensure  the  best 
possible  image  /  Les  pages  s'ooposant  ayant  des 
colorations  variables  ou  des  decolorations  sont 
filmees  deux  fois  afin  d'obtemr  la  meilleure  image 
possible. 


This  ilc:n  :s  Mmed  at  !t-,e  reduction  ratio  checked  lielov*  / 

Ce  document  pst  tilmc  au  taux  de  reduction  indique  ci-dessous 


lOx 


14x 


18x 


12x 


16x 


20x 


22x 


26x 


30x 


24x 


28x 


32x 


The  copy  filmed  here  has  been  reproduced  thanks 
to  the  generosity  of: 

J.J.  Talman  Regional  Collection, 
D.B.  Weldon  Library, 
University  of  Western  Ontario 

The  images  appearing  here  are  the  best  quality 
possible  considering  the  condition  and  legibility 
of  the  original  copy  and  in  keeping  with  the 
filming  contract  specifications. 


Original  copies  in  printed  paper  covers  art  filmed 
beginning  with  the  front  cover  and  ending  on 
the  last  page  with  a  printed  or  illustrated  impres- 
sion, or  the  back  cover  when  appropriate.  All 
other  original  copies  are  filmed  beginning  on  the 
first  page  with  a  printed  or  illustrated  impres- 
sion, and  ending  on  the  last  page  with  a  printed 
or  illustrated  impression. 


The  last  recorded  frame  on  each  microfiche 
shall  contain  the  symbol  — *►  (meaning  "CON- 
TINUED"), or  the  symbol  V  (meaning  "END"). 
whichever  applies. 


L'exemplaire  film^  fut  reproduit  grace  A  la 
g^n^ijsit^  de: 

J.J.    Talman  Regional    Collection, 
D.B.   Weldon  Library, 
University  of  Western  Ontario 

Les  images  suivantes  ont  6t6  reproduiies  avec  le 
plus  grand  soin.  compte  tenu  de  la  condition  et 
de  la  nertet6  de  l'exemplaire  film*,  et  en 
conformit*  avec  les  conditions  du  contrat  de 
filmage. 

Les  exemplaires  originaux  dont  la  couverture  en 
papier  est  imprimAe  sont  film^s  en  commencant 
par  le  premier  plat  et  en  terminant  soit  par  la 
derniire  page  qui  comporto  une  empreinte 
d'imprf  ,sio"  ou  d'illustration,  soit  par  le  second 
plat,  s   f  jn  le  cas.  Tous  les  autres  exemplaires 
originaux  sont  film*s  en  commenpant  par  la 
premiere  page  qui  comporte  une  empreinte 
d'impression  ou  d'illustration  et  en  terminant  par 
la  derniAre  page  qui  comporte  une  telle 
empreinte. 

Un  des  symboles  suivants  apparaitra  sur  la 
derniAre  image  de  cheque  microfiche,  selon  le 
cas:  le  symbole  —^  signifie   'A  SUIVRE  ',  le 
symbole  V  signifie   "FIN  ". 


Maps,  plates,  charts,  etc.,  may  be  filmed  at 
different  reduction  ratios.  Those  too  large  to  be 
entirely  included  in  one  exposure  are  filmed 
beginning  in  the  upper  left  hand  corner,  left  to 
right  and  top  to  bottom,  as  many  frames  as 
required.  The  following  diagrams  illustrate  the 
method: 


Les  cartes,  planches,  tableaux,  etc..  peuvent  etre 
filmAs  A  des  taux  de  reduction  diff^rents. 
Lorsque  le  document  est  trop  grand  pour  etre 
reproduit  en  un  seul  cliche,  il  est  film^  ^  partir 
de  Tangle  supArieur  gauche,  de  gauche  ^  droite. 
et  de  haut  en  bas,  en  prenant  le  nombre 
d'images  n^cessaire.  Les  diagrammes  suivants 
illustrent  la  m^thode. 


1  2  3 


1 

2 

3 

4 

5 

6 

MICROCOPY    REiOLUTION    TEST    CHART 

ANSI  and  ISO  TEST  CHART  No    2l 


1.0    If 


I.I 


1^  1 2.8 

32 

36 


2£ 
1.8 


1.25  i  1.4   mil  1.6 


js     APPLIED  INA^GE     Inc 


THE  DIAGNOSIS  AND 

TREATMENT  OE 

ACID(3SIS 


15V 

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lRpiirinli>d    rom  Tin;  ST,  I'Afl,  Mf:i):CAI.  .lOURNAr,. 

.!:inw;irv.  1917  t 


•UK  DIACXdSlS  A\J)  TJiKAT.MKNT  OF 
ACIDOSIS.^ 


i 


L.  (.'..  RowNTKi-j;,  M.  D.. 

Proft^ssor  nf  M.cli.. '1h\  riii\.  r-ii>-  uf  .Minm.cotii. 

Miiiiu-apolis.  Mi)i!i. 

Tlicori'tically  ;ni(l  |)rai/ticaliy  acidosiH  is  (if 
'■xtrciiK'  interest:  1o  the  scientist,  on  account  of 
llif  inpcnions  protective  iiieclianiMus  furnislieil 
liy  nature  to  maintain  an  aeiij  liase  ei|uilil)riuni : 
to  the  clinician,  on  account  of  its  freiiucut  oc- 
curi'cncc  in  many  clinical  ■■onditions. 

iu'cenlly  newer  methods  have  heen  intro- 
durcl  which  make  possible  an  earlier  and  more 
preeise  diagnosis  of  acidosis  and  throw  consid- 
erable lii,'ht  up(jn  the  mechanism  whereby  the 
condition  arises.  'Hie  mon'  I'eady  clinical  diag- 
nosis of  an\  [lathoiogic  condition  naturally 
leads  to  a  moi'e  successful  ti'eatment,  and  an 
understaniiing  of  the  mechanism  whereby  it 
arises  leads  towards  successful  priijihylaxis  and 
rational  therapy. 

The  priiblcm  ot'  aiddosis  is  embraced  in  the 
much  large]'  one  of  the  maintainance  of  the 
acid  base  eiiuilibi-ium  in  the  liody.  There  are 
diii'erent  types  of  addusis.  ench  being  depend- 
ent perhaps,  to  a  very  gr.'at  extent,  on  the  clin- 
ical associations  iu  which  we  find  it.  So  far  as 
1  can  rerall.  1  have  never  sr(>n  or  reail  ol'  a  case 
of  primary  idiopatliie  acidosis.  it  is  always 
seeondar.x.  It  arises  in  many  clinical  condi- 
tions, some  of  \,liirh  We  will  diseuss  later,  and 
the  ditt'erent    elinieal   assiiei;itions  control   to  a 

•Ue.id  tiHturi-  Oie  Snuiheru  Miuiir-.ti  Mi>,lir«l  .\ssnciKti.jii  h: 
KocUdKr.  Minii     Aagu'ti  M.  Itlie. 


ii 


e 


lar^'c  extent  the  (liffcrent  matiifcstalions  whicli 
we  may  tiiid  in  acidosis.  In  oilier  words,  aci- 
dosis liecoiiies  a  part  of  various  vicious  eireles, 
and  we  iiave  to  consider  acidosis  alone  and  in 
association  with  the  other  elenn'nts  concerned 
in  these  vai'ious  circles. 

That  ditVerent  types  of  acidosis  e.xist  is  very 
evident  wlicn  once  we  begin  to  study  tlie  sub- 
ject. Altli(»u?li  there  has  been  a  tremendous 
amount  written  concerning  it.  there  has  really 
been  very  little  added  that  is  fundamental  in 
character  since  the  masterly  presentation  of  the 
subject  ))y  Henderson  in  1009.'  A  great  deal 
has  been  done  which  is  not  fundamental,  but 
which  deals  with  methods  of  determining  aci- 
dosis and  with  its  clinical  associations.  These 
are  the  lines  along  which  progress  has  been 
made  since  Henderson's  coiitribution. 

In  connection  with  acidosis  we  want  to  con- 
sider for  a  moment  the  sources  of  acids  as  they 
occur  in  the  body.  Tiiese  are  indicated  in 
Table  i. 

TABLK  1. 
Origin  of  Acids  in  Living  Organisms. 

H.SO.-'Oxidation  of  S  of  proteins. 
H,HO  —Oxidation  of  I^  of  .iroteins. 
H  CO3  or  CO. — Oxidation  of  organic  matter  from  or- 
ganic acid. 
Lactic) 

Uric    )  excreted  as  such  in  small  amounts. 
Food — amino  acids,  etc. 


Let  us  consider  next  tlie  mechanisms  pro- 
vided by  nature  for  taking  care  of  the  acids  as 
they  accumulate  from  metabolism  or  as  they 
are  taken  into  the  body.  The  most  important 
acid,  I  should  say,  is  the  carbonic  acid.  The 
carbon  dioxid  arises  from  oxidation.  Its  seat 
of  highest  tension  is  in  the  tissues.  It  is  trans- 
ported from  these  seats  of  high  tension  to  seats 
of  lower  tension  by  the  plasma  and  cells  of  the 

2 


r> 


liliioil.  Till'  carlion  ilioxid  is  taken  iii)  l)y  the 
NailL'O,  of  plasma,  is  trausportod  from  tiio 
tissues  to  tiie  blood  stream,  thenee  to  t.ie  lungs, 
from  the  lungs  to  the  alveolar  air,  and  from  the 
alveolar  air  to  tiie  outside  air. 

The  second  big  factor  we  have  to  consider  is 
the  urinaiy  secretion.  The  important  part  the 
kidney  plays  in  the  I'revention  of  acidosis  has 
only  recently  been  recognized.  The  blood  is 
constantly  alkaline,  not  markedly,  but  definite- 
ly so,  and  the  kidney  separates  out  from  that 
lilood  a  urine  which  is  definitely  acid.  It  ex- 
cretes large  quantities  of  acid.  If  the  urine  is 
titrated  back,  from  tlie  standpoint  of  its  ability 
to  take  care  of  alkali,  its  acidity  is  \'>and  to 
vary  from  200  to  800  e.  c.  of  N  acid. 

1  want  to  sho.v  you  by  means  of  equations 
two  or  three  reactions  which  occur  in  the  body 
and  vhieh  are  a  part  of  the  mechanism  for  tak- 
ing care  of  the  acid. 

\aIICO=  -f  IICl  =-  NaCl  +  HO— CO..  We 
have  here  sodium  bicarbonate:  if  hydrochloric 
acid  is  added  we  get  a  neutral  .salt  which  is 
excreted  by  the  kidney  while  the  COj  resulting 
is  excreted  by  the  lungs.  This,  according  to 
Henderson,  is  the  first  line  of  defense  of  the 
body  against  acid. 

The  second  equation 

Na2HP04  +  HCl=NaCl=NaH2P04. 

shows  another  type  of  reaction.  AVe  obtain  the 
acid  phosphate  which  takes  care  of  a  consider- 
able amount  of  acid,  but  in  itself  it  is  not 
markedly  acid,  and  NaCl  a  neutral  salt. 

By  the  third  reaction 

Na2HP04  +  H30fCO.  =  NaHiP0  4  +  NaHC03 

we  not  only  get  rid  of  the  acid,  but  we  actually 
save  the  alkali  for  tlie  tissue.    There  is  formed 


% 


;in  ;iciil  |ili(is|iliiil('  wliicli  is  oxiTftril  in  tin' 
mini'  ;niil  sddiuiii  Iticarlioiuiti'  wliii'li  is  riMaiiii'il 
ill  till'  lilood,  pai'tii'iiiiii'ly  in  tiic  hlood  plasm. 
'I'lic  NallCO  is  ilic  iiiosi  iiii|iiirtaiit  constitui'iit 
ol'  the  lihiDi!  plasma  so  I'ar  as  llir  coiiiliat inj^  ol' 
acidosis  is  eoncei'ni'd. 

'I'll*'  tliii'd  fai'liir  is  tlie  hiilTer  [)roperty  of 
lilooil.  l'>\'  liiiI'lVi'  wi'  mran  ili:'  property  ol'  a 
lliiid  whcrcliy  ii  takrs  rari'  of  coiisiderahlt' 
i|iiaii(  itii's  III'  I'ilhcr  arid  or  alkalirs  witliont  it- 
srit    miili'i  noiiiii    any   iioi  ii'i'alilf   clianj,'!'    in   ri'- 

arlioii.  Wi-  li;i\i'  SUrIi  a  tluid  ill  till'  hlood.  Wi' 
ran  add  to  tlh'  lilood  very  lar!.'i'  ipiant  itirs  of 
lillirr  acid  or  alkalies  \vitii(nit  changing  its 
ariiial  lead  ion.  That  is  iiroiight  about  by 
three  I'aetors.  l-'ii'st.  by  till.'  carbonates  and 
biearboiiales  ;  seeoiid.  |'!iospliates.  jia rticulai'ly 
sodium  and  potassium  jihosphates :  aiiil  third 
and  liiiall>\  llic  pr.iieiiiN.  These  three  fador^ 
pla,\'  ail  iiiipori.iiii  ruh'  in  making  up  the'  bulVer 
\  alue  ol'  the  blood. 

TAIU.E   IT. 
Summary  of  Buffer  Values.* 


No.  '.f  ■•:t.e>  ;iiil1 
'I'Mcriiiiii.i'  iiMi> 

< 
o.lS 

o.lS 

o 

24 

0.36 

'               9 

0.075 
o.lO 

o,05C 

0.13 

9                                       16 
Acidosis 

24 

p 

Coiiiiien- 

O.lO 

O.20 

safpd.                       g 

1 

•For  method  of  detfrminintr  Hyilroffcn  Ion  concen- 
tration and  bufftr  value  of  the  blood  s.  o  articlo;-.  by 
I.fvy.  Kownlrec  and  M.inioit.  Airh.  Int.  Med.,  s-'iit. 
1915,  p.  389. 

I,i\\-  and    nowntrcc.   .\icti.   Int.   Mel,,  .\eril,    I'.iHi,  ji.   '.rl'i. 


<l 


"V 


lu  this  tahle  is  shown  some  work  wliiuh  in- 
dicates that  the  blood  and  plasina  lose  their 
power  to  taki  care  of  aeids  and  alkalies  in  aci- 
dosis. In  carrying  out  this  work  we  added  to 
a  certain  quantity-  '  ■  ..3  a  iixod  quantity,  2 
c.  c.  of  blood  or  plaf  ■ncre^-sin^'  amount  of 

•J  acid  and  alkali. 

In  acidosis  the  blood  itself,  in  vitro,  is  less 
,11  liable  of  takint?  care  of  either  acids  or  alka- 
lies witlout  undergoini;  change  in  reaction. 

Finally  the  k  .t  protective  mechanism  is  the 
in'oductiou  of  ammonia.  This  we  are  apt  to 
think  of  as  one  of  the  most  fundaiDcntal  pro- 
cesses, but  it  does  not  play  so  important  a  part 
in  a  large  number  of  cases.  It  is  important  in 
the  types  of  acidosis  in  which  we  have  aceto- 
nuria.  We  may  have  tiie  most  extreme  grades 
of  acidosis  under  certain  conditions,  particu- 
larly in  neiihritis,  without  the  slight.-st  change 
in  the  ammonia. 

Table  HI  indicates  the  various  tests  which 
have  been  used.  I  am  showing  a  large  number 
ard  will  call  attention  to  the  more  important 
of  them.  Certain  of  these  tests  can  be  dis- 
carded. 

TABLE  III. 
Urinary.  Alveolar  Air. Blood. 

NH,N— amount.  jCO,  content. 

— %  of  TnPN.Haldane— art. 
Acetone  bodies- I'lesch— venous 

amount.             Fridericia— art. 
Alkali  tolerance.  Flesch-Levy. 

Sellards. 


Palmer  & 
Henderson. 


Sensitiveness    of 
respiratory 
centre. 
Peabody. 


Hydrogen-ion  con- 
centration. 

1.  A.  Hydrogen 
electrode. 

B.  Dial— Indi- 
cator. 

2.  Alkaline  re- 
serve— 
Van  Slyke. 

3.  Titratable     al- 

kalinity. 

4.  Buffer  value. 

5.  Curve  of  Hb 

dissociation. 

6.  Acetone  bodies. 


Marriott. 
5 


Marriott. 


].  Urinary  Studies.  The  ammonia  nitrogen 
of  the  urine.  I'ln'  ii mount  exereted  is  iiiereased 
in  all  cases  where  there  is  a  marked  acetonu- 
ria.  It  is  not  an  essential  feature  of  acidosis. 
We  can  have  an  extreme  grade  of  acidosis  with- 
out any  elian^'e  whatever  in  the  acetone  bodies 
in  the  urine.  "We  must  draw  a  strong  distinc- 
tion between  aeetonuria  or  ketonuria  and  aci- 
dosis. The  terms  have  been  used  synonymous- 
ly, and  on  that  a  'eount  have  led  to  mistaken 
ideas  in  medicine,  but  wo  must  draw  a  sharp 
line  between  them. 

Acetone  bodies.  In  certain  types  we  do  have 
tliese  aci  ;onc  liodies  in  the  urine,  and  when 
dealing  with  starxatiou  or  diabetes  it  is  impor- 
tant to  know  about  Ihem,  l)ut  aeetonuria  is  not 
au  essential  feature  of  acidosis,  as  we  liave 
already  indicated. 

Alkali  t*"-'  "ance.  Tiiere  are  two  tests — Sel- 
lards'-  and  raimer  and  Henderson's.'  Sellards 
found  that,  in  tiie  normal  individual,  ten  grams 
of  sod'um  'licarbonate  cause  i  tiie  urine  to  be- 
come alkai,  in  reaction.  In  other  words,  the 
tolerance  is  a|iproximately  ten  grams  before 
there  is  any  cliange  in  reaction.  He  found  that 
in  a  large  lu'reeutage  of  eases  of  acidosis  this 
did  not  occur:  tlial  SO  lo  100  grams  might  be 
necessary  before  a  elianire  in  reaction  oecurred. 
Palmer  and  Hi'nderson  determined  the  amount 
of  change  in  reaction  of  urine  folh)wing  the 
ailiiiinistratioii  of  4  gms.  of  XallCO^  liy  UiOuth. 

The  Hydrogen  Ion  Concentration  of  the 
Urine.  The  variations  in  normal  individuals, 
Hs  fouiiil  by  Henderson  and  Palmer,  arc  great. 
Imbed  they  niay  be  as  gi'eat  as  in  acidosis 
cases;  so  great  tiiat  1  do  nut  helieve  the  test  is 
of  any  great  clinical  value. 


Both  of  these  tests  aie  at  fault  wlieu  it  eoiues 
to  the  study  of  renal  eases  in  whieh  tliey  liave 
been  applied.  I  do  not  believe  they  should  be 
used  in  renal  eases  l)eeause  tliey  are  misleading. 
"We  know  that  in  nephritis  the  kidney  fails  to 
excrete  a  great  many  substanees.  It  may  be  a 
dye  substance:  it  may  be  nitrogen:  it  may  be 
salt,  or  water.  We  cannot  take  the  failure  of 
the  urine  to  become  alkaline  on  tiie  administra- 
tion of  a  certain  amount  of  alkali  as  an  index 
that  acidosis  exists,  because  it  may  be  purely 
and  simply  an  index  of  renal  in.sufliciency,  and 
the  renal  insufticiency  may  be  of  an  extreme 
grade  without  the  Blightesl  acidosis.  These 
tests,  therefore,  cannot  be  applied  in  cases  with 
renal  insufficiency,  but  they  may  be  used  to 
great  advantage  in  conditions  siich  as  diabetes. 

2.  Respiratory  Studies.  Alveolar  carbon 
diaxid.  Several  metliods  have  been  introduced 
to  determine  the  alveolar  CO.-.  I  sliall  discuss 
briefly  the  relative  merits  and  the  case  of  appli- 
cation of  some  of  these  methods. 

The  determination  of  the  alveolar  carbon 
dioxid  is  one  of  tiie  most  important  things  in  the 
study  of  acidosis.  Some  one  of  tlicse  methods 
ouglit  to  be  used  or  be  replaced  bv  the  method 
of  Van  Slyke.  which  determines  the  ability  of 
tiie  lilood  to  take  ui)  CO..  Ilaldanc'.s  method 
(4)  and  the  Fredericia  method  (5)  give  in  real- 
ity tlie  tension  which  exLsts  in  the  arterial 
blood.  The  method  of  riescli  ((5)  differs  from 
llaldane's  and  Fridericia's  in  that  the  patient 
rebreathes.  Instead  of  breathing  into  a  tube, 
collecting  the  alveolar  air  at  the  end  of  expira- 
tion, the  patient  rebreathes  and  coiisccpiently 
the  carbon  dioxid  tension  corresponds  to  that  of 
the  venous  blood  rather  than  that  of  the  ar- 
terial blood. 


• 


Dr.  Ia'v.v,  \vl)ii  workt'd  with  lai'  last  year  in 
lialtiinori',  tricil  to  make  tlie  method  of  Pleseh 
luoi'.'  <;viiernii.v  api'lieahle.  and  I  liave  here 
iustniineiit  wlifli  demonstrates  his  method  of 
enlK-tiny:  the  alvrohir  ear'non  dioxid  utilizing 
tlic  prim-iph'  of  rehreathinfr. 

j'l'ahudy  i7^  has  called  attention  to  the  in- 
creased sensitiveness  of  the  respiratory  centres 
in  aci<losis:  in  (itiier  words,  rehreathing;  or  in- 
creasine-  the  earlion  dioxid  tension  of  inspired 
tr'iiiendiiuslv     increases     the 


an' 


rate     and 

dejith  (if  I'csjiiration  in  acidosis  as  compared 
witii  the  normal.  Tiie  sensitiveness  of  the  res- 
piratory centre  is  greatly  increased  in  aeidosis. 
Tills  is  true  in  tin'  majoriiy  of  eases,  hut  tins 
elTecf  may  he  overshadowed  hy  tlu'  influeiiee  of 
certain  tliseases  or  dnigs  which  do  not  stimulate 
lint  jiaralyze  the  I'esiiiratory  centre. 

In  any  study  of  acidosis  we  iiave  to  consider 
some  one  of  these  nu'thods.  In  our  work  we 
have  tised  the  riesch-Levy  method  of  collecting 
the  alveohir  earlmn  dioxid.  wi'h  the  Ilaldane 
determination.  The  ohjection  to  the  l'"ridericia 
api>aratus  is  that  with  this  instrunu'nt  air  can- 
not he  satisfactorily  collected  from  the  iiatient 
except  with  intelligent  coii|ieration.  One  can 
make  a  collection  hy  the  JMescli-Levy  metiiod 
and  the  determination  of  CO:  by  the  Friderieia 
apparatus.  Tahle  IV  shows  the  results  of  a 
series  in  which  both  the  l'"ridericia  and  Ilaldane 
determinations  were  made. 

These  are  all  indirect  methods  of  studying 
acidosis.  Tliey  \vere  introduced  because  of  the 
great  technical  ilifliculty  standing  in  the  way 
of  direct  methods  of  investigation  of  the  blood. 

:>  Blood  Studies.  We  speak  of  acidosis,  but 
know  absolutely  nothiiig  coiicerniiig  the  condi- 
tion of  (he  tissues      The  neai'cst  we  can  come 

8 


TABLK  IV. 
Comparison  of  Fridericia  and  Haldane  Methods  of  De- 
termining Alveolar  CO.  with  Plesch-Levy 
Collection. 


Case 


Hosp. 
No 


'reiiil'. 


fridericia     Haldane 
mm.  Hg.  ,  mm.Hg. 


Hi'iiKirki 


~C —     I    8455 


22 
P—     I    836Sr]^ 

ir48fn~2^2 


i  29. S  I  2'J.t;  , Pregnancy  at  lerm. 
1  22.3  1  21.9    9  days  post  partuni. 


22~~|"ljr3'r30j2|^aybj)osti)artuni. 
'22Y^[22^Q~\1  days  post jiartuni. 

S^== — fl!498~|^22     T  4«.6~^f40.4  ,12days  post  partum. 

B^n^8508    f  22     135.2  134.8  ,9  days  post  partum. 

H— "^1    8522    I     22     |  35.3  I  35.00, ludayspo^tjmrtuui. 

-qZ:     V~ZZ        j~23     I  47.9  I  47. 4    Noniial. 

23~  I  44.3  I  44.0  |NoiiJial. 

"^23     r  49.2"  i~48.9'|Nornial. 


Z—     I    — 


G—    I   - 

to  till'  .stilt.'  Ill'  llif  tissues  is  Ihi'  lil'iod  aifl 
pluMua.  We  .■ousi.l.T  tiiat  llic  blond  rctlorts 
eondiliuns  iis  tliuy  .-xist  in  llie  tissues  and  tins 
atVonis  tlu;  uh.sI  din'rt  liii.'  of  approacii  \n  tin- 
invi'st ligation  ol'  acidosis. 

Tlicre  aro  a  great  many  met  hods  that  have 
been  used.  First,  the  liydrogen  ion  eoneentra- 
tion  of  the  l>lood  by  the  jras  ehain  luethod. 
Tills  is  earried  out  with  a  llyd^o^'en  ele.lrude. 
It  re(|uires  an  v\V  ■  i\e  pieee  of  apparatus  and 
a  man  trained  In  physirs  to  use  it.  In  other 
wonis,  it  is  absolutely  impraetieal  as  a  elnneal 
method.  I.at.-ly  we  have  introdueed  a  substi- 
tute -a  simple  meth.Ml  of  Kettin<r  at  the  hydro- 
iivn  ion  eoneeiilrati.H)  of  the  Mood,  whieh  1  will 

demonstrate. 

We  have  a  systrm  of  pluisphale  mixtures 
whieh  vary  m  Uieir  alkalinily.  The  more  al- 
k;iline  (Mies  are  colored  red.  the  less  alkaline 
and  acid  tul-es  yellow  sulph.uieplithalcin  beintr 
used  as  an  iiidi.  .itor.  We  liav  a  j,'radual 
transition  from  the  yellow  until  we  f,'et  to  the 
red.  Now  each  mi.xlurc  has  a  detinitely  known 
bydroK'eii   iou   concentration.     When    we    want 

9 


lo  dcteniiiiu'  the  liydrogeu  ion  concentration  of 
'hlooil  we  i>laee  two  or  tlirco  cc.  oi"  blood  in  one 
of  tlh'se  collodion  tubes,  place  that  tube  in  a 
siiiail  j:iass  tulie  containing  salt  solution,  leave 
it  for  Tt-S  minutes  and  Mien  rei.iove  it.  Dialysis 
occurs  friiiii  the  lilood  tiiroufrh  the  -Dllodion  tube 
into  tiK'  salt  solution.  We  now  add  an  in- 
dicat.)!-.  rhenolsulpiioneplithalein  will  yield 
■.,iic  (if  the  colors  of  the  scale,  i.  e.,  the  hydro;,'en 
ion  concentration. 

Whereas  it  took  one  to  two  and  une-half  hours 
to  make  a  dctcrminatiun  with  the  old  method, 
we  have  made  as  many  as  forty  determinations 


r.M'.id':  V. 

pH    Determined   by   Electrometric  and  Dolysis- 
Indicatur  Methods. 


No. 


MHtert&l 
1  .S  cc. 


|,M 


Ct)j    IKN-loN 


Kl»"i-t. 


Diiil.  Iiid. 


1. 
2 

3. 
4. 
5. 


plasma 

IiUisniu 
lila.'^niu 
plasma 
plasma 


1% 

3% 

5% 

10% 

10% 


8.05 

7.9 

7.G 

7.43 

7.4 


8.1 
7.9 

7.i; 

7.1 
7.4 


Experimental    Data. 


Dog. 


la. 
b. 
c. 

11.     I 

lUa. 

b. 


Wl,  kft. 

"I'lTl" 


11.8 
17.1 


Couiliiiiin 


Nciiiniil 

ir.o  cc.  iiHCl. 

ISO   cc.    8% 

NaHCO, 

4t)5  <c.  S% 
111   shock 
Normal 
In    '-liocU 


pit. 


Elret. 

Dliil.-Ind 

7.5 

7.5 

.6.8 

6.S 

7.5 

7.5 

7.7* 

7.6.-.*» 

7.2 

7.15 

7.4 

7.4 

7.2 

7.15 

Clinical  Data. 


I'll 


I'utlvnt. 


Il"i<p.  Nil. 


Klect. 


i=     1 

8-        I 


8140 
8234 
823« 


1.0 

7.5 
7.6 


Dlitl.-  nd. 


7.45 

7.5 

7.6 


•Kleclroinwtrlc  method  on  nrtorlal  tilood. 
♦♦Dialysis  Imlicat'  r  mullui'l  on  Ncnoiis  blood. 

10 


in  one  afternoon  with  ^  's  little  apparatus. 
Y^hm  iirst  introduced,  we  elaimed  only  relative 
values  lor  this  method.  ^Ve  now  claim  that  it 
gives  ahsolute  values  for  hydrogen  ion  concen- 
tration Since  coming  to  ^linneapolis,  m  col- 
laboration with  Dr.  J.  F.  McClendon,  1  have 
iKul  tlu-  opportunity  of  comparing  the  results  ot 
this  method  with  those  of  the  eh'ctrometric 
method.     The  results  are  given  in  Table  V. 

The  alkaline  reserve  of  Van  Slyke,  This 
nut  hod  was  introduced  a  year  ago.  It  is  the 
,uost  d.licat..  ami  the  most  valuable  of  any 
sin.'le  test  for  acidosis.  It  can  be  applied  with- 
out nuich  techni-al  diflirully,  but  requires  the 
Van  Slyke  aiiparatiis. 

The  titratable  alkalinity.  Tlds  is  a  test  which 
is  applied  without  any  siKcial  apparatus  but  it 
is  o.ilv  a  .-MOSS  test.  An  alcoliol.c  tiltrate  of 
|,l„od'or  plasiuu  is  cvaporatrd  in  a  poivrlain 
l„nvl.  ;.n  indicator— phenoli«hthalein— being 
ji.l.Ud.  This  .letermiues  whetlicr  or  not  the 
solution  turns  red  or  not  during  evai.oration 
ami  the  p-int  at  whi.di  the  red  api^ears.  Ad- 
vantage IS  taken  of  the  variations  in  dissocia- 
tion of  the  salts  in  water  and  alcohol.  It  is  a 
simple  gross  method,  applicable  without  any 
sp.rial  appariitus. 

■n„.  bullVr  valur  1  have  alivady  discussed. 
Iniisuiueli  ;is  it  is  not  constantly  decreased  in 
.-very  rase  ui  neidosis,  nsasingle  test  it  is  of  no 

great  value. 

Till-  .urve  (if  the  heiiiogbduii  dissociation  was 
„„roduee,l  i.v  P.,ncrol-t  .S  .  1  have  not  had 
,„u.-i,  ,s|.,,,cnee  Nvllh  d.     It  is  teehnieally  .lil- 

lieldt. 

■n„,  acetone  bodice  in  the  Mood  eells  can  lie 
,l,.(,oMnined  I.v  methods  uitrodu.  ed  by  Si'lialVer 
and    Mainntt    (!•;. 

11 


• 


Terminology.  1  iiiighl  say  a  word  about  the 
toniiiuolosiy.  At  the  present  time  tliere  is  no 
term  in  met'liral  literature  whieh  is  more  loosely 
used  than  acidosis.  AVe  should  try  to  have  a 
elear-L-Ui  (•(Uieeption  of  acidosis.  From  a  labor- 
atory point  of  view  this  is  essential.  In  acid- 
osis there  is  a  decrease  in  the  alkaline  reserve, 
in  the  bicaflmnate  foutcnt  of  the  blood  as  deter- 
mined liy  the  Van  .Slyke.  Associated  Mitii  this 
we  have  a  decrease  in  llie  carbon  dioxid  of  the 
alveolar  air.  If  we  have  this  occurring  while 
the  protective  mechanisms  are  suflicieut  to  pre- 
vent an  actual  change  in  the  hydrogeu  ion 
concentration,  the  condition  is  one  of  compen- 
sated acidosis.  l>ut  if  an  actual  change  in  reac- 
tion occurs,  i.  e.,  a  hydrogen  ion  eoncenti'ation 
just  about  normal,  the  condition  is  one  of  true 
acidosis,  for  wc  have  passed  tlie  stage  where 
protective  iiiechanisais  suflice.  This  termino- 
logy is  much  the  sanu'  as  is  used  by  llasselbalch. 

Clinical  Aspects.  The  mo.st  imiiortant  single 
cluneal  e\  ideuce  of  acidosis  is  hyiierpnoea  (air 
liunger  .  It  should  always  suggest  acidosis, 
but  it  does  not  always  prove  it.  1  have  seen 
delinite,  iiniiiisl.iUablc  hyperpuoea  in  alkalosis, 
(increased  alkalinity  of  the  blood  i.  Ketonuria 
or  acctouuria  and  "acetone  on  the  breath"  are 
also  !in|ioitant.  They  develop  in  certain  types 
of  cases,  jiarticulariy  in  patients  with  diabetes, 
and  in  st,ii\  ation.  When  marked,  ketonuria 
usually  Hcans  acidosis,  but  it  nuiy  be  absent  in 
line  acidosis. 

Tile  \'ai  ions  diseases  in  which  we  have  acid- 
osis is  shown  below. 

].      Diahetes. 

'J,      Kcnal.  caiilioi-cnal  and  cardiac  disease. 

:i.     ( 'ijriirrtic  stiites  siUil  scverc  aucmias. 

4.  Se\eic  diarrhoea  (, part ieularly  in  chil- 
dren  .      (!()' 

in 


^ 


5.     Cholera.     Sellards.     (11). 
G.     Starvation. 

7.  rrcgiiaiicy  and  I'claiupsia.      (12). 

8.  I'dst-ojierativr    or    i>osf-aiH'^tlH4ic    ooudi- 

tidtis.  pai'tii-iilarly  in  s\u'u'ii-al  sliock. 

!t.     Certain  febrile  diseases. 

Diabetes.  Here  we  t're(iiiently  have  acidosis, 
with  aeetone.  diacctir  arid  and  1".  oxyl)utyrie 
acid  in  tlio  urine,  and  an  aeelone  odor  in  the 
breatli  alonj,'  witli  air  hiiniicr.  Is  death  under 
these  eireuiiistames  due  to  aridosis.'  Aeldosis 
is  present  in  the  majority  of  young  eases.  I 
want  to  speak  about  this  heeause  thei'e  is  a  dif- 
ference of  opinion.  I  doul)t  whether  many  of 
these  patients  die  from  the  actual  inei'ease  in 
hj'drogen  ion  concentration.  Tiie  aeenmulated 
bodies,  aside  from  changes  in  the  reaction,  have 
mui'h  to  do  with  the  outcome.  I  have  seen  pa- 
tients with  diabetic  acidosis,  true  acidosis,  to 
whom  we  have  given  alkalies  in  tlie  way  of 
treatment,  in  whom  we  have  coiTcted  tlie  hy- 
drog(>n  ion  concentration,  brought  back  the  al- 
veolar carbon  dioxid  and  the  alkaline  r'serve  to 
jormnl,  die  in  typical  conia.  .\1)normal  acids 
in  the  blood  and  tissues  may  ]>lay  a  great  role. 
This  is  in  keeping  with  the  findings  of  Erh- 
mann  and  Esser  (13)  which  show  that  death  in 
coma  occurs  in  animals  \vhen  thr  sodium  s;dls  of 
oxybulyric  acid  is  administered  id  large  quan- 
tities, 

T  woidd  like  to  c;dl  allentioi>.  to  one  expe- 
rience T  have  had  in  the  last  three  or  four 
weeks.  1  was  called  to  see  a  mi'u  witli  an  en- 
larged |ii'ostate  wiir)  liad  diabetes,  and  the  (|ues- 
tioii  aiose  v  •;■  il-.'-r  the  surgeon  eoidd  operate, 
he  had  0.4;':;  sugar  in  the  blood— (piite  high. 
He  was  pitting  out  ^arsre  (;uanlities  of  stigar 
in  the  urine.  ^Ve  init  him  on  sodium  bicarbon- 
ate, gave  him  .\llen"s  treatment,  and  later  kept 

13 


liiiu  v.itliiu  his  toliTaiicL'.  An  operation  was 
IJcrronued.  lie  developed,  after  operation, 
marked  !.'l\i/osiiria  altliou;.'!!  no  extra  earbo- 
liydralrs  w.re  j^ivni.  lie  had  a  di'iinite  aeoto- 
nuria.  llr  had  sonu'  dia<'etie  aeid,  hut  not  a 
trace  of  ai.-ido.sis.  His  alkaline  rrscrvu,  his  al- 
veolar CO.,  and  his  hydrogen  ion  uoneeutration 
were  strictly  normal  and  he  showed  no  elinical 
signs  of  acidosis.  Dietary  control  was  exer- 
cised and  he  made  a  perfect  recovery. 

Cardiorenal  cases.  Acidosis  does  occur  in 
certain  cases  of  jcnal  insufliciency,  hut  the  most 
e>i.treiue  grade  of  uremia  may  exist  without  any 
suggestion  of  it. 

I  M-ant  to  jMesent  an  interesting  '-ase  showing 
some  results  in  acidosis  and  uremia.  Table  VII 
indicates  the  nndiiigs  of  a  case  seen  in  consulta- 
tion with  Dr.  .Schneider  of  .Minneapolis.  This 
]>atieiit  rei-ei\ed  alkaliiie  treatment  sufliei''nt  to 
correct  ids  acidosis  hut  he  died.  In  other  words, 
it  is  posiMe  to  ceiTcet  aeiiiosis  witliout  curing 
reiml  insuili'-ieiiev. 

TAr.LK  Vil. 


%=\xl\fi^\t^'=^ 


<  S  '  '  "i  '  i  "f  oer  100  cc.  ti. 


4-17 
4-19 

4-20 


2y.72,".2  .  —    j  97ji71,  —  ,    7Vo   |i\aUCU     15 

I  I          1        I       I         I            iBiiis.    liail.v 

26.15  7.3  ,30.4  |181  .206|  24    Trace^iloO  cc.  4',;, 

!  I          I        i       I         '  1-02  InuHCO,   I.V. 

25.67'7.5  37.57,158  ;203|  19 


.1  I        I 

Before   —    i  —  ,24.59-        |       j 

4.22     I         ;        1         [9111711 

After   i  —    |7.6  ;26.45|        | 

4-24     130.4  I7.45i  —    I  87  il62 


1.09 


600  cc.   i''c 
NaHCO.  1.  V. 


.41  ! 


Before   —    7.3  t31.7  j84.5|  —  j  —  j    —   iTransi'tisioii 

<-25     1         1  111 

After   |39.4    7.4531.94  67    1  --  j  —  ,     - 


• 


14 


<L 


» 


1  l)elicvt;  then;  are  a  great  many  patients  in- 
jured witli  too  lari,'e  quaulities  of  alkalies.  One 
should  know  what  irrade  of  aeidosis  he  is  deal- 
infT  Avith  tlirougli  lal)oratory  studies.  The  acid- 
osis eau  l)e  corrected  witli  alkali.  You  can  tide 
over  c(/rtain  cases.  1  luive  seen  an  occasional 
patient  markedly  iiiii)roved,  but  I  have  never 
seen  a  case  o!'  chronic  interstitial  nephritis  that 
has  gone  on  to  this  grade  of  renal  insut'ticiency 
with  uremia  g^'t  AVt  11  or  eh'ar  ui)  for  any  length 
of  time  fdllowing  the^coi'rection  of  the  acidosis. 
Acidosis  is  only  one  feature  of  the  picture  and 
you  cannot  always  cure  tiie  palii'Ut  by  correct- 
ing the  acidosis.  1  lia\c  seen  many  instances  of 
marked  decrease  in  alveolar  carbon  dioxid  oc- 
curring in  cases  of  chronic  interstitial  nephritis 
and  iiolycjstie  kidney  4  IjcIow  12  mm.  llg.  the 
lowest  being  down  to  7mm. 

Cachexia.  .Veidosis  in  cachexia  was  called 
to  my  a;  tent  ion  iiy  a  case  of  carcinonui  of  the 
stomach,  ^.itll  metastasis  to  the  li\ei\  The  pa- 
tient presented  the  tyi»ical  pictui'e  of  acidosis, 
and  the  anemia  api'arently  had  little  to  do  with 
it. 

The  results  of  some  experimt-ntal  .•inemia  in 
dogs  is  shown  in  Table  VI II. 


TAl 

I.K  Vlll. 

Effects 

of    Bleeding. 

\vt   III           Aivr,.|»r 

Alkii'iiiP 

Tiiut 

,, t'<i; 

U  serve 

i 

■^^"'~      1    III  iiiiii.  Uii. 

ill  iniii.  IIk 

Dog 

6-14-16                1 

1 

I.      jBeforo  bleeding 

17       I       39.83 

29.13 

Iiuiiieiliat(-I\ 

' 

after  til.'rdins 

5U0  cc. 

:iivs:! 

30. 

6-ii;-ii; 

k;.'?         :'.8..s:! 

46.51 

Dog  1    6-1 1- It; 

II.        Before    liiee.lin« 

?1.S           4it..'j7 

37.38 

Imnu'(liatrl\ 

,     alter  bleetling 

600  cc, 

ill..'. 

37.38 

6-16-16               1 

21.r.    ;       41.e3 

44,67 

15 


€ 


Pregnancy  and  Eclampsia,  llassellialch 
rlriius  tliat  acitlosis  is  frequent  iu  pregnaney. 
What  is  acidosis?  He  takes  as  evidence  of 
acidosis  any  li<.'un3  for  the  alveolar  earhon 
(lioxid  l)elo\v  40.  If  acidosis  does  occur,  it  is 
slight,  as  indicated  by  our  studies.  In  eclamp- 
sia, however,  -we  find  definite  evidence  of  it. 
Five  cases  out  of  seven  showed  a  d'^finite  in- 
crease in  tlie  hvilrogen  ion  concentration,  i.  e., 
true  acidosis.  The  alveolar  carbon  dioxid  and 
carbon  dioxid  eapaiMty  of  the  blood  is  de- 
creased. 

TABLE  IX. 
Acidosis   in    Eclampsia. 


Name 


Date 


ili'uinrks 


K— 
H— 


B— 
H— 
P— 

S— 

H— 


-     \1.Z  I  -    i     - 
.6-  9-15i7.y  I  —    I     — 


|Recovery. 

jT.n.F.N.    307    mgm. 
I  1       I  i  jt'rea  X.  2.'iG  mgm. 

I  |Alk.    toleranct;    15 

i  '  !  igm.+ 

,4-2S-16  7.3D'30.38|  24.67  |Dled. 

'4-2!i-]t;  7.;{,")'23.02    2.5.3     Revocery. 

u-  2-16,7.45;  —    j  33.22  I'uorperal       tonvul- 

I       j  I  I     sioiis. 

6-  3-16!  — 135.     !  34.9    'Died. 
(i-22-167.3.5:35.     I  33.      ;Convalsions. 
t;-27-16i7.5    35.3      39.      | 


Our  scries  is  too  small  to  admit  of  any  con- 
clusions ri'lali\e  to  its  constancy.  Kigiit  cases 
only  have  beex  studied.  True  acidosis  %vas 
present  in  live.     The  lindin-.'  appear  iu  table  IX. 

Acidosis  in  Anesthesia  and  Surgical  Shock. 

Four  post-opcrati\i!  cases  exhibiting  clinical 
evidence  of  acidosis  were  sludii^d — two  prosta- 
tectomies, one  neiihrotomy  and  one  drainage 
of  gall  bladder  with  bile  peritonitis.  All 
showed  t  rue  acidosis. 

<  'linically  we  hav(>  had  no  oii[iortuiii1.\'  for  the 
study  of  acidosis  iu  relation  to  surgical  shock. 

It) 


In  collahoratiou  with  Ur.  J.  F.  Corbett,*  experi- 
mental slioek  is  being  studied  at  present.  Here 
true  acidosis  develops  as  indicated  by  the  fol- 
lowing table. 

TABLE  X. 


Do;; 

Tinip 

^   1 

1£      1 

"H.      -(.x  1  <S 

Remarks 

AE  910 

9:30 
l:3u 
4:30 

2r> 

7.4  ]43.7  1 
7.1  j3S.t3  I27.G 
7.0  128.4  {32.8 

AE  913  ' 

8:30 

21.8t 

7.4  i."i4  ti 

40.9 

4:30 

1 

7.0  |32.1 

37.1 

AE  926 

9:30 

2,-.. 

7.45,31.7 

43.9 

12:30 

7.:i  1  — 

22.6 

3:30 

t 

7.1  :32.1 

25. C 

AE  911 

9:30 

18.0; 

7.5   iTiiti 

48.3 

12:30 

7.45'38.5 

— 

4:30 

7.2  |_— 

39.5 

AE  940 


S:40 
3:30  [ 


4:00  1 

5:30  1 

30 

8:30 

3:03  i 

3:22  ' 

4:05  1 

1 

19.1!  7.5  :56.2    54.7  j3: 2.5— 150  cc. 
I  7.3  ]42.9  |2G.4    Ringer'f  solution. 
I  7.1  [38.0  J41.4  !3:30— 100  cc.5% 
1  7.4  142.0  I          iXaHCO,. 
24.  i  7.45  52.9  156.5  |3:03— 2U0  cc. 
I  7.3528.9  |26.8  jHo'^an's  solution 
\  —    :39.3  ]40.8  i3:22— 2u0  cc. 
!  —    |46.5  |47.9  IHogan's  haemol- 
,         i  !  I  I     ized. 

The  effect  of  XallCO^  iii)on  ])lood  pressure  in 
shock  affords  additional  evidence  of  the  exist- 
ence of  acidosis.  Tracing  I.  is  a  chemographic 
tracing  showing  the  fall  of  blood  pressure  ac- 
companying shock  and  tlie  response  to  the  ad- 
ministration of  NallCO.  The  effect  of  Ringer's 
solution  is  also  indicated.  The  second  tranng 
demonstrates  le  elfect  of  Ilogan's  gelatine  al- 
kaline mixture  in  experimental  shock. 

Starvation.  It  is  a  common  belief  that  starv- 
ation results  in  acidosis.  That  acidosis  may  oc- 
cur is  not  denied,  but  as  the  result  of  study  of 
starvation  dogs  we  feel  convinced  that  the  role 
of  acidosis  is  extremely  slight.  Here  again  ke- 
tcnuria  is  the  more  marked  feature.     From  an 

•Separate  report  to  be  published  later. 
♦To    be  published  later. 

n 


Z 

o 


is 


# 


I 


• 


19 


uut,-oiarletril  sliuly  imw  in  progretis  in  niy  de- 
pai'tmeut  liy  Dr.  Nortiiington  ;ind  Dr.  Grave,* 
it  ai>pear.s  tliai  llie  role  of  aeidosis  is  almost  neg- 
ligible for  t.Mi  days  at  least  in  starvation.  Ke- 
tonuria  iiMially  develops  within  48  hours  and  its 
presence  has  been  eonstrued  into  evidenee  for 
acidosis.  Alkaline  reserve,  alveolar  CO-,  and 
jdl  of  the  blood  remain  normal  for  the  first  ten 
days  but  later  tiie  alveolar  CO^  indicates  a 
slight  teiideney  to  decreased  tension.  The  re- 
sidts  of  these  experiments  are  shown  in  tables 
XI  and  XII. 

TABLH  XI. 


e-a-j-tti  to) 
7-6-it;       ) 

Daii.v  exams.) 
of  acetone  ) 
and  diacetic) 


6-14-it; 

H-ir)-16;   33.1 

t;-i6-i6 

fi-17-18 

»;-lH-16i'  33.1 

6-2ii-ltii 

t;-21-16  31.6 

S-22-23 

6-24-161  30.'. 

t;.2S-16'  29. r. 

fi-30-16|  28.6  I  28.47 

7-  3-161  28.4  1  27.74 

7-  6-16|  28.1  I  26.78  

Treatment  of  Acidosis.  Alkali  treatment  is 
always  indicated  in  acidosis,  because  a  duiunu- 
lion  in  bicarbonate  reserve,  as  jiointetl  out  by 
L.  .1.  licndeison.  is  an  invariable  aecompaui- 
ii'.enl  of  acidosis  regardless  of  other  eo-e.\isting 
changes.  The  di  gree  of  the  aei<b)sis  siiould  be 
determined  preliminary  to  the  administration 
of  alkali  sinei  tlie  degree  of  aeivlosis  controls 
tlu!  intensity  of  treatment.  The  more  severe 
tiie  acidosis  tiie  more  alkali  is  iiidiea'ed.  Alkali 
sliould  be  administered  at  least  until  the  pll  of 
the  blood  returns  to  normal.  It  is  desirable 
20 


|irrli:i|is  to  i-orrcct  llio  alvcdlni'  CO-  jiiid  alkuli 
rrsiTxi'  ;is  Well.  ;ill  lioii'-'ti  tliis  is  no',  alwavs  so 
rcfidily  ai-c()iiii)lislii'(l. 

TABLE  Xll. 


Date 

Wt,  in 

<  -  = 

<—  - 

V  V 

a  c 

■<.9 

—  o 

.1 " 

Keiiiiirk-* 

t;-i3-i6 

16.3 

42.3 

46.7 

Small 

t;-i4-iG 

•> 

0 

fat 

iM.'i-lC 

ir..4 

■:,'.K\ 

40.4 

0 

<l 

t'emalp. 

<;-iti-i(i 

Trare 

0 

ti-lT-l« 

+ 

n 

(Ms-it; 

-i- 

0 

t;-i;t-ii; 

14,:. 

.'iD.n 

v,.\:, 

0 

0 

t;-2(i-iti 

+ 

0 

ti-;ii-iii 

14..-. 

38.8:) 

42.26 

+ 

0 

n-22-it; 

— 

i;-2:3-it; 

+ 

0 

i;-24-iti 

i:;.7 

44. 3t! 

51.42 

+ 

0 

ti-25-16 

+ 

0 

ti-26-l(i 

+ 

+ 

(;-2T-l(> 

+ 

+ 

i;-2K.16 

i;i. 

;!7.42 

40.19 

+ 

+ 

\\  lirii  till'  1  r^'aliiiciit  is  iiiti/iisi\('  ali<aiosis  rr- 
siills,  a  roiitlilioM  luit  little  studiril  ami  little 
midrrstootl.  ('Iiart  J  ilhist fates  the  f,n'adiial 
ile\-(do|iiiii'iit  of  acido.sis  and  of  all<alosis  as  the 
ifsult  res|"'i-li\'ely  of  slow  adiiiinisl  ral  i<iii  iii- 
tia\ciioiisly  of  !;•  IK'I  and  .")',  N'alK.'O^^ 
i  )iatli  r''sidtcd  in  hotli  instaiiees. 

i'lic  usual  i-liniral  ell'ecls  of  alkaline  tn-at- 
nnuit  ai'i'  relirf  of  dyspnora,  diui'esis,  with  oera- 
sioiially  mental  iiniiroNcnient.  With  letiial 
ainoutits  oi'  alkali  eoaise  tremors  and  rij^idity 
di'\('lo|i  and  linally  xomitinfr,  eonvulsions,  and 
relaxation  of  the  sphinetHis  l;i<j:or  moi'tis  is 
inimediale  and  extreiiie. 

(  linii'all\  at  t  inirs  oedema  and  aseiirs  devtdop 
durini,'  alkali  adniinislrati(U).  .\side  from  al- 
kali therapN'  alkalosis  is  rarely  eneountered. 
\.r\\  ami  I  have  found  it  only  in  thi>  following: 
(•oiiditions  typhoid,  followintr  transfusion  in 
prnnar>-  and  secoiid:ir>'  anemia  and  in  nephritis 

:>i 


Wilson  nnd  Pti'iiiiis  (14:  (IciiioiistratiMl  its 
lifi'sence  in  cx|ioriiih'ii1;illy  iiiduceil  tiMniiy  in 
(logs. 

At  tlio  i)resunt  time  it  must  he  admitted  that 
our  knowlcdtjro  of  aui<losis  is  not  pi'ot'ound.  Re- 
latively simple  methods  of  deteriiiining  its  ex- 
istence and  intensity  are  now  available — the 
same  methods  serving  for  the  eontrol  of  ther- 
apy, 'riirongh  their  use  a  dei'per  nudei'stand- 
itiL'  iif  aciilosis  must   I'i'siili.      Moi-c  exact,  and 

therefore  iiuu'e  ell'cctive.  Ircatmeiif  can  1 on- 

lidently  aniieipated. 


€ 


UIBLIOORAI'HY. 

Honilevson,  L.  .1.:  Das  (Ileichgew  ieht  zwischeii 
Itasen  und  Siiuren  iin  tiiMsclicn  OrKanisnm.s. 
Ergl).  (1.  I'h.vsiol.,  li>ii!i,  viji,  p.  2.' I. 

Sellai'ds,  ,\.  W.:  Tlio  (Iclpriiiiiiali  .ii  of  the  ('(|iii- 
liliriuiii  in  the  luiiiian  lioily  lie  ,eoii  iicids  ami 
liases,  Willi  siioiial  reterc'u  lo  aeidosi.s  and 
iiephropattiies.  .Johns  Hop.  Hosp.  Tliill  .  101?, 
xxiii.  p.  2S0. 

Scllard.-^.  A.  \V,:  A  clinical  ni.'lluid  lor  .^lud>iii^' 
titratalile  alkalinity  ol'  the  blood  and  its  aiipli- 
cation   to   acidosis.      Ibid,,    liUI,   xxv,   ji.    101. 

I'alnicr  anil  Ilendei.-on;  Clinical  studies  on 
acid-base  (Mjuilibiiuni  and  the  nature  of  a<'i- 
dosis.      Arch     of   Int.    .Med..    l!M:i.   xij,   p.    l."i:l. 

Talihcr  and  lleiiderscn:  dn  the  extroiiies  of 
xarialion  of  the  concentration  of  ionized  hy- 
di(if;en  in  huniaii  urine.  Jour.  Uiol.  Chemistry, 
l'.)i:i,  xiv,   p.   !."■:!. 

llnldaiie  and  l'rie-lle>:  .lour.  I'hysiol.,  lite.'., 
xxxii,  p.  '22'k 

llaldano  and  I'oulton:      Ibid.,  11)08,  xxxvii,  p.  390. 

Haldane  aiul  Hoyrott :     Ibid,  lOii.S,  xxxvii,  p.  lifin. 

Haldane  and   n<iUKlas;      Ibid,  l',to:t,  xxxviii,  p.  420. 


•In  alluU'isis  the  CO  ol  IiIocmI  and  nf  tin-  alv  'olar 
air  are   widely   dl\erKcnt. 

'I'llP  writer  wishes  to  acKiiowledte  his  indebted 
nt'SS  to  Miss  Winnifred  Swifl  for  valuable  technical 
assifitaurc. 


11'. 


i:;. 


II 


I"ridpiiri,-i ;  ICinc  klinische  ifctliode  zur  Bestim- 
iiiuiiR  (ler  Kolilensiiurespannung  in  der  Lun- 
wnliift.     liprlin  klin.  AVochen.,  lOH,  li   (2),  p. 

1268. 

I'lescli  Method  df  obtainiiiK  alveolar  air.  Zeit. 
1'.  exii.  I'alh.  u.  Tlierap.,  11109,  vi,  p.  3S0. 

I'eabody:  Clinical  Studies  on  Respiration.  No. 
I,  The  Kfl'e(  t  of  CO.  in  the  inspired  air  on  pa- 
lients  with  caidiac  diseaj^e  An  h.  of  Int. 
Med.,  .Nov.   I.'.,  1913,   p.  S4«. 

liarcroft:  The  l{esi)irator.v  Function  of  ihe 
Blood.     Cambridge   Cniversity   I'less,   1914. 

.Sihafl'er  aiul  Marriott:  The  determination  of 
acetone.  .Nephelometric  determination  of  min- 
ute ipiantitie.s  of  acetone.  The  determination 
or  11.  ox.N  butyric  acid  in  blood  and  ti.ssiie.s. 
Jour,   Hiol.  Clieni.,   1913,  .\vl,  p.  26."!. 

-Marrioii:  The  blood  in  acidosis  froui  the  ipian- 
titative  .standiioint.  ,Iour.  r.iiil.  Cheiu.,  1911, 
xviii,  p.  ."jOT. 

Hov.land  and  Marijoti:  .\cidosis  occurring  with 
diarrhoeas,  American  .lour,  of  l)is.  ol  Chil- 
dren, Vol.  xi.  .No.  Ti,  p.  309. 

SclUiiils:  Tolerance  toi  alKalie.s  in  .^.siatic  Cho- 
lera.    I'hiiippine  Jour    rfi  ience.  191'i.  v.  ;iu3. 

Sellards  and  yiiaKlee:  Indications  of  acid  intox- 
ication in  Ahiatic  cholera.     Ibid,,  1911,  vi,  p.  53 

llasselbahh  and  Cammeltoft:  Die  .Veutralitats 
refzulation  des  gi  aviden  Oiganismus.  Hiochem 
Zeit..  191,'..  Ixviii.  p.  2u!>.  .Abstracted  in  ,lour 
A.  M,  A,  Oct    2,   191.",  Ixv,  p,  ll9i.i, 

l\hrnjaiin  and  Ksser:  Ceber  experimentalles 
Kdnia.  Zeitschr.  f.  klin.  Med.,  Vol.  72.  1911,  p 
49«. 

Wilson  and  Stearns:  'I'he  cITect  of  a<id  admin 
islration    on    luiratliyroid    tetany.      Jour,    liijl 

Chem  ,   191.'..  xxi,    .i,!i. 


23 


